Health inspection·September 11, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm schizoaffective disorder, need for assistance with personal care, obesity, hyperlipidemia, hypertension and bipolar disorder. R63's Minimum Data Set (MDS), dated [DATE], documents, in part, that R63's Brief Interview for Mental Status (BIMS) score is a 6 which indicates that R63 has severe cognitive impairment. Residents Affected - Some On 9/10/24 at 11:49 am, when asked about the process of nurses administering medication, V2 (Director of Nursing, DON) stated that the nurse will bring the medication cart close to the resident's room and prepare the medications. V2 stated that the nurse will then verify the five rights (right patient, right medication, right route, right time, and right route) during the medication preparation, and the nurse will bring the medications to the resident, explain each medication to the resident, and will give the medications to the residents. V2 stated that the nurse must ensure that the resident has swallowed the medications and need to be present to make sure (resident) really took the meds properly. When asked if medications like pills in a medicine cup are left unattended by the licensed staff (nurse) in a resident's room, V2 stated that the nurse would not know if the resident took the medication on their (residents') own as ordered, and If the resident did not take the meds, anyone could take that med. It's accessible to everyone. V2 stated, This is a safety issue. V2 stated that a medication self-administration assessment needs to be completed to confirm that a resident is cognitively competent to administer the medication unsupervised (without licensed staff present). This surveyor requested the medication self-administration assessment for R63, and V2 stated that V2 would have to check. On 9/11/24 at 9:27 am, V27 (Assistant Administrator) emailed this surveyor to respond to the follow up on V2's check for R63's medication self-administration assessment, and V27 documents, This is not applicable; (R63) is not able to administer (R63's) own medication. R63's Medication Administration Record (MAR) for September 2024 documents, in part, that R63 is ordered to receive the following medications: Aspirin 81 mg (milligram) tablet oral daily (scheduled at 9:00 am); Docusate Sodium capsule 100 mg oral twice a day (scheduled at 9:00 am); Metoprolol Tartrate tablet 25 mg oral every 12 hours (scheduled at 9:00 am); and Sennosides 8.6 mg tablet oral twice a day (scheduled at 9:00 am). Facility document titled Daily Census and dated 9/8/24 documents, in part, that 52 residents are residing on the 4th floor of the facility. Facility policy dated November 2020 and titled Administering Medications documents, in part, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safety and resident has successfully completed a competency for self-administration. Facility job description (undated) titled Registered Nurse (RN) documents, in part, The primary purpose of a Registered Nurse's position is to provide each of the residents with routine daily nursing care and services in accordance with each resident's assessments and care plan. Registered Nurse (RN) Essential Duties and Responsibilities: Works using the guidelines established from the Nurse Practice Act and Policies and Procedures and nursing judgement. Assesses, plans, and evaluates nursing care delivered to patients/residents requiring long-term or rehabilitation care. Delivers nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 2 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm care to patients/residents requiring long-term or rehabilitation care. Implements the patient/resident plan of care and evaluates the patient/resident response. Directs and supervises care given by other nursing personnel . Maintains knowledge of necessary documentation requirements . Conducts self in a professional manner in compliance with unit and facility policies. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 3 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain residents' call lights within reach of residents to use for staff assistance which affected two residents (R63, R303) in the total sample of 76 residents when reviewed for accommodation of needs. Residents Affected - Few Findings include: On 9/8/24 at 11:21 am, this surveyor entered R63's room and observed R63 laying in bed. R63's red call light string is observed attached to the call light activator (on the wall) and is looped through hook on the wall to extend the red call light string towards R63 in bed; however, R63's red call light string is observed hanging on the opposite side of R63's nightstand table (3 drawers) which is clearly out of R63's reach in bed. This surveyor went to the doorway to the hall and requested that V24 (Certified Nursing Assistant, CNA) who was walking by to enter R63's room. When asked V24 where is R63's call light, V24 retrieves the red call light string from the behind R63's nightstand table and clipped it to R63's pillowcase with it now being within R63's reach. When asked where should R63's call light string be placed, V24 stated, It should be clipped on the bed or pillow, within reaching distance of the resident. R63's admission Record documents, in part, R63's diagnoses of dementia, adult failure to thrive, schizoaffective disorder, need for assistance with personal care, obesity, hyperlipidemia, hypertension and bipolar disorder. R63's Minimum Data Set (MDS), dated [DATE], documents, in part, that R63's Brief Interview for Mental Status (BIMS) score is a 6 which indicates that R63 has severe cognitive impairment. R63's Functional Abilities and Goals for Mobility documents, in part, that R63 is coded as substantial/maximal assistance-helper (staff) does more than half the effort for rolling left to right in bed, and R63 is coded as dependent-helper (staff) does all of the effort for sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfer. R63's Care Plan documents, in part, a focus of R63 at risk for falls related to dementia, incontinence, adult failure to thrive, schizoaffective and bipolar disorders, medication regimen and need for assistance with personal care (dated initiated 8/6/21, revision date 7/25/24) with an intervention of ensure call light is within reach and encourage the resident to use it for assistance (dated initiated 8/6/21, revision date 9/13/23). On 9/9/24 at 11:49 am, when asked where a residents' call light should be placed by staff, V2 (Director of Nursing, DON) stated It should be placed accessible and close to the patient (resident), within their reach. When asked the purpose of having the call light within the reach of the resident, V2 stated, So the patient (resident) can be able to access it to call for any help when needed. R63's Order Summary Report documents, in part, an order of Fall Precautions with an active order status of 8/8/21. Facility job description (undated) titled Certified Nursing Assistant (CNA) documents, in part, A Certified Nursing Assistant (CNA) provides quality nursing care to residents while implementing specific procedures and programs related to resident care under supervision of assigned Charge Nurse (LPN or RN). Certified Nursing Assistant (CNA) Essential Duties and Responsibilities: Provides (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 4 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few individualized attention to residents which encourages each resident's ability to maintain or attain the highest practical physical, mental and psychosocial well-being . Contributes to the resident care planning process by providing the charge nurse or other care planning staff with specific information and observations of the residents' needs and preferences. Attends to residents' activities of daily living which may include assistance with feeding, grooming, bathing, oral hygiene, feeding, incontinent care, toileting, colostomy care, prosthetic appliances, transferring, ambulation, and range of motion, communicating or other needs in keeping with the individuals' care requirements . Answers residents' call lights promptly and courteously. All other duties as assigned. Findings include: R303 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Hypertension, Pulmonary Embolism Without Acute Cor Pulmonale and Type 2 Diabetes Mellitus. R303 has a Brief Interview of Mental Status score of 11. On 9/08/2024 at 10:02am surveyor observed R303's call light device attached to the pillow behind R303's head and not within reach. Surveyor observed R303 reach for the call light device, but she could not reach it and R303 said, No, I cannot reach the call light. On 9/08/2024 at 10:07am V4 (LPN) stated no, she (R303) can't reach her call light. On 9/08/2024 at 10:35am V5 (Certified Nursing Assistant-CNA) stated call lights should be close to the resident, at all times. On 9/10/2024 at 12:32pm V2 (Director of Nursing-DON) stated call lights should be within reach and closest to the resident. R303's care plan focus for falls with a revision date of 7/29/2024 documents, in part, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Call light policy with a revised date of 11/2013 documents, in part, when a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 5 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident has a physician's order for a code status (Full Code or DNR, Do Not Resuscitate) in the resident's electronic medical record (EMR) which affected one resident (R196) in the total sample of 76 residents reviewed for advanced directives. Findings include: On [DATE] at 2:11 pm, V19 (Licensed Practical Nurse, LPN) and V37 (LPN) were observed sitting at the nurse's station on R196's floor. This surveyor asked V37 how does V37 know the code status of V37's assigned residents, and V37 stated, We (nurses) know from here. It comes from here, as V37 is pointing to the computer screen with the electronic medical record (EMR) system is visible. V37 stated that the resident's code status for full code (life-sustaining treatments) or DNR (not providing certain treatments and/or allow natural death) is listed on the profile screen for each resident which is the first screen the nurse sees when viewing each resident's EMR. V37 stated, There is supposed to be an order for full code. V37 stated that the advance directives are determined by the resident or the family wishes and that it depends on what is in here in the EMR. V37 stated that the residents' code status can also come from the hospital transfer orders, and then the nurse will enter the code status order in the EMR under the orders tab. V37 stated, I (V37) will put in the code status order, and then it populates into the profile screen. When asked how the nurse knows to provide emergency resuscitation if a resident would go into cardiac arrest in the facility, V19 stated, I (V19) check the resident profile to provide the emergency services for whatever is there (on the profile screen). V37 stated, We (nurses) need to look (at the profile screen). R196's admission Record documents, in part, R196's diagnoses of dementia, cognitive communication deficit, major depressive disorder, hyperlipidemia, hypertension, neuropathy, diverticulitis of intestine, arthritis, and disorders of bone density and structure. R196's admission Record documents, in part, the categories of resident information, payer information, other information, pharmacy, external facilities, contacts, diagnosis information, advance directive and miscellaneous information; and R196's advance directive category is blank. R196's Order Summary Report with active physician orders as of [DATE] does not include a physician order for R196's code status. R196's Minimum Data Set (MDS), dated [DATE], documents, in part, that R196's Brief Interview for Mental Status (BIMS) score is a 6 which indicates that R196 has severe cognitive impairment. On [DATE] at 11:49 am, when asked about how the nurses know the code status of their residents, V2 (Director of Nursing, DON) stated, We (nurses) have it in the system (EMR). When you open it (resident's EMR), the code status is right there. On the profile screen, and it tells the resident's name, age and code status. V2 stated that the nurse will enter the physician order for the resident's code status (full code or DNR) in the EMR, and it will populate in the (EMR) on the profile. When asked if each resident needs to have a physician order for code status (full code or DNR) in the EMR, V2 stated, Yes. Correct. V2 stated that the full code or DNR order needs to be in the EMR, so the nurses know what emergency resuscitation services need to be provided in case of an emergency. V2 stated that the full code or DNR is verified by the family, and then the nurse will put order in the EMR. When asked what if a resident and/or family has not decided on the code status and there's no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 6 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician order placed in the EMR, V2 stated, We still have to have it for emergency. It should be there (in EMR). V2 stated that until a decision is made about code status, the resident will be treated as a full code status, and the resident will have an order for full code in the EMR. Facility policy dated [DATE] and titled Advance Directives documents, in part, Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: . 10. The plan of care for each resident will be consistent with his or her documented treatment preference and/or advance directive . 15. our facility has defined advance directives as preferences regarding treatment options and include, but are not limited to: a. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated . e. Do Not Resuscitate indicates that, in cases of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representatives (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used . h. Life-Sustaining Treatment - treatment that, based on reasonable medical judgment, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures. Event ID: Facility ID: 145792 If continuation sheet Page 7 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete sections of a resident's minimum data set accurately to reflect the resident's health status. This failure has the potential to affect 1 resident (R153) in a sample size of 76. Residents Affected - Few Findings include: Record review of R153's admission Record documents in part the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting the left-non dominant side, dementia in other diseases classified elsewhere, unspecified psychosis. Record review of R153's Minimum Data Set (MDS) dated [DATE] documents in part that R153 has clear speech (distinct intelligible words), is able to be understood, and able to express ideas and wants. Additionally, R153's MDS dated [DATE] documents that the Brief Interview for Mental Status (BIMS) should not be completed, resident is rarely/never understood (incongruent data). On 9/8/2024 at 10:59 AM, V6 (Registered Nurse Supervisor) stated that R153 is hard to understand when speaking and can't talk very well. On 9/9/2024 at 11:08 AM, V44 (MDS Nurse, Registered Nurse) stated that V44 completes Section B of the MDS (Hearing, Speech, and Vision) and that V38 (Social Services Director) completes the BIMS. Surveyor reviewed the 7/23/24 MDS with V44 and V44 affirmed that R153 has clear speech and can be understood. V44 recalled that V44 completes other interview sections of the MDS with R153 and R153 is able to complete them but often refuses. V44 affirmed that if R153 is able to be understood, then the BIMS portion of the MDS should have been completed. V44 affirmed that the RAI (Resident Assessment Instrument) instructs staff how to complete the MDS. On 9/10/2024 at 11:38 AM, surveyor observed R153 communicate with V44. R143's speech was not clear and R153 spoke with a very quiet, strained, raspy, whisper. When V44 asked R153 where are you right now? V44 had to ask for clarification because surveyor and V44 could not understand R153's reply (indicating resident is not always understood). On 9/10/24 at 11:41 AM, V38 (Social Services Director) stated that V38 is assigned to complete the BIMS score for R153. V38 stated that when V38 attempted to complete the BIMS interview, R153 refused, so V38 coded C0100: Should Brief Interview for Mental Status Be Conducted? as 0. No (Resident is Rarely/Never Understood). V38 affirmed that R153 is able to be understood and C0100 should have been coded as yes. Record Review of CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2023, documents in part, . B0700: Makes Self Understood (Cont.) . Coding Instructions Code 0, understood: if the resident expresses requests and ideas clearly. Code 1, usually understood: if the resident has difficulty communicating some words or finishing thoughts but is able if prompted or given time. They may have delayed responses or may require some prompting to make self understood. Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet). Code 3, rarely or never understood: if, at best, the resident's understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet) .C0100 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 8 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Should brief interview for Mental Status Be Conducted? (cont.) Coding Instructions Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; Cannot respond verbally, in writing or use another method; Or an interpreter is needed but not available. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, and one is available. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 9 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer one resident R170 to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R170 was diagnosed with a new mental disorder. This deficient practice affected one resident (R170) in a total sample size of 76 residents. Findings include: R170's PASARR dated 03/03/23 documents in part, PASRR Level I Determination: No Level II Required No SMI (Serious Mental Illness)/ID (Intellectual Disability)/RC (Related Condition). R170's admission date to the facility is 03/04/2023. R170's medical diagnosis with dates include but are not limited to Chronic Obstructive Pulmonary disease (03/09/23), Other Asthma (03/04/23, Schizoaffective Disorder (03/09/23), Paranoid Schizophrenia (04/18/23), Other Schizophrenia (04/18/23), Bipolar Disorder Current Episode Mixed Severe Without Psychotic Features (04/18/23), Major Depressive Disorder (04/18/23), Anxiety Disorder (04/18/23), Paranoid Personality Disorder (04/18/23), Delirium Due to Known Physiological Condition (04/18/23), Essential Hypertension (03/04/23). Record review of R170's chart show no new PASARR was completed after new mental disorder diagnosis. Facility's policy titled PASARR Guideline dated 12/2022 documents in part, Preadmission Screening And Annual Resident Review (PASARR) Guideline .Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly .Objective PASARR Guideline .The objective of the PASSARR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified .f. Coordination of Care .iv. The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative. On 09/10/24 at 10:29am V38 Social Service Director (SSD) stated, R170 was admitted on [DATE] and R170's PASARR was done on 3/3/23. When a new PASARR is needed I (V38) would initiate the level 1. The only way I (V38) would know if a resident needs a new PASARR is if I (V38) am told. R170 has some diagnosis of Paranoid Schizophrenia, Bipolar, Major Depression and Anxiety. Either one of the diagnoses I (V38) just listed for R170 would indicate a need for a new PASARR or level 2 PASARR. R170 should have had another PASARR completed after his mental health diagnosis. On 09/10/24 at 2:27pm V38 stated, I (V38) just submitted a new Level I PASARR for R170. R170's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 8, which indicated R170's cognition is moderately impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 10 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R170's physician order dated 04/18/23 documents in part, Monitor behaviors: Episodes of agitated, angry, screaming/yelling, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, isolative behaviors and depressed interventions. R170's care plan dated 07/21/24 documents in part, R170 uses psychotropic medications related to Bipolar Disorder, Other Psychoactive Substance Dependence In Remission, History of Schizoaffective disorder, Delirium due to known Physiological Condition, Schizophrenia, Paranoid Personality Disorder, Anxiety Disorder, Unspecified Mood (Affective) disorder. Event ID: Facility ID: 145792 If continuation sheet Page 11 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a pre-admission screening and resident review (PASARR). This failure affects 1 resident (R153) in a sample of 76. Residents Affected - Few Findings include: Record review of R153's admission Record documents in part the following diagnosis: major depressive disorder, unspecified psychosis not due to a substance or known physiological condition. R153' Face Sheet documents R153 was admitted to the facility on [DATE]. Record review of R153's electronic medical record does not indicate a PASARR was completed. On 9/10/24 at 9:53 AM, V27 (Assistant Administrator) affirmed that there was not a Level I PASARR completed for R153 prior to the start of the survey. V27 provided a Level I PASARR that documents in part a submission date of 9/9/2024 and determination outcome for R153 dated 9/10/24. Record review of facility provided policy titled, PASARR Guideline (Revised 12/2022) documents in part, The PASARR process consists of the completion of a Level I screen per State and Federal requirements as well as the review and implementation of the level II recommendations upon admission into the facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 12 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to invite and conduct care plan conferences to include the resident in development of their plan of care. This failure affects 1 resident (R136) in a sample of 76. Findings include: Record review of R136's admission record documents in part, the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affective left-non dominant side, unspecified dementia without behavioral disturbance, protein calorie malnutrition, and osteoarthritis of the left hip. Record review of R136's minimum data set (dated 8/16/24), documents in part a brief interview of mental status score of 11, indicating that R136 is cognitively impaired. On 9/8/2024 at 10:19 AM, R136 stated that R136 has never been invited to participate in the development of R136's plan of care. R136 denied ever participating in a plan of care meeting (care conference). R136 affirmed that if there was a meeting held to discuss R136's plan of care, R136 would want to participate. Record review of R136's progress notes (care conference notes) document in part on 6/14/2023, V45 (Careplan Coordinator, Licensed Practical Nurse) contacted R136's emergency contact to set up a care plan. No documentation was made that R136 was invited to a care plan meeting or that a care plan meeting occurred. On 9/9/2024 at 11:02 AM, V45 affirmed that V45 is the staff member that coordinates the care conferences in the facility and that care conferences are held quarterly and as needed, aligning with the MDS (Minimum Data Set) calendar. Surveyor inquired when the last date that R136 had a care conference, and V45 replied that R136 has not had a care conference. V45 did not know the reason why R136 has not had care conference or why R136 was not invited. V45 affirmed that residents have the right to attend care plan conferences and participate in developing their plan of care. Record review of facility titled, Care plans, Comprehensive Person Centered (Revised 4/2017) documents in part, . The Interdisciplinary Team (IDT), in conjunction with the resident and, resident representative or family or legal representative, develops and implements a comprehensive, person- centered care plan for each resident . 3. The IDT includes: . e. The resident and the resident's legal representative (to the extent practicable) . 7. The care planning process will: a. Facilitate resident and/or representative involvement; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 13 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that two residents (R40 and R199) who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving. This failure affected two out of 76 residents reviewed for ADL care. Residents Affected - Few Findings include: R40's Brief Interview for Mental Status (BIMS) dated 08/22/24 shows that R40 has a BIMS score of 08 which indicates that R40 has moderate cognitive impairments. R40 has a diagnosis which includes but not limited to: unspecified dementia, major depressive disorder, and bipolar. R199's Brief Interview for Mental Status (BIMS) dated 08/22/24 shows a BIMS score of 6 which indicates that R199 has some cognitive impairments. Surveyor interviewed with R199, and R199 was alert but not able to answer questions appropriately. R199 has a diagnosis which includes but not limited to: need for assistance with personal care, muscle weakness and dementia. On 09/08/24 at 10:16 am, R40 was observed in bed awake, and alert ungroomed with facial hair beard and mustache visible. When surveyor asked R40 regarding being shaved R40 stated that R40 does not know the last time that R40 was shaved and that R40 does not shave herself (R40). On 09/08/24 at 10:28 am, R199 was observed in the dining room, alert ungroomed with facial hair beard. When surveyor asked R199 regarding being shaved R199 shrugged R199's shoulders and indicated that R199 did not know when the last time R199 was shaved. On 09/09/24 at 11:16 am, R40 was observed in bed resting, ungroomed with facial hair beard and mustache remain visible to R40's face. On 09/09/24 at 11:18 am, R199 was observed in the dining room, alert ungroomed with facial hair beard remain visible to R40's face. On 09/09/24 at 11:31 am, Surveyor questioned V34 (Certified Nursing Assistant, CNA) regarding residents being shaved and V34 stated, I (V34) do not have R40 I (V34) only have R199. I (V34) should have shaved her (R199) today, but I (V34) didn't. When V34 was questioned regarding who is responsible for shaving the resident and how often are residents shaved, V34 stated, The CNA's are responsible for shaving the residents. Every chance we (referring to the CNA's) get (referring to how often the CNA's are expected to shave the residents). When V34 was asked regarding the importance of ensuring residents are shaved, V34 stated, For the residents dignity. On 09/10/24 at 11:37 am, Surveyor questioned V2 (Director of Nursing, DON) regarding the facility's expectation for shaving female residents and V2 stated, Shaving female residents with visible facial hair is a part of ADL (Activities of Daily Living) care. Female residents are shaved the same as male residents. Shaving female residents should be offered daily if the Certified Nursing Assistant (CNA) see visible facial hair. When V2 was asked regarding the importance of shaving female residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 14 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 V2 stated, For the dignity and hygiene of the resident. Level of Harm - Minimal harm or potential for actual harm R40's MDS (Minimum Data Set) dated 08/22/24 shows that R40 requires maximum assistance with ADL care personal hygiene. Residents Affected - Few R199's MDS dated [DATE] shows that R199 is dependent with ADL care personal hygiene. R40's care plan dated 12/01/23 documents in part: Focus: R40 requires ADL assistance related to Parkinson's Disease, COPD (Coronary Obstructive Pulmonary Disease)/Asthma, muscle weakness, vitamin D deficiency, cerebral ischemia . Intervention: Personal Hygiene/Oral Care: R40 requires substantial/maximal assistance x1 staff with personal hygiene an oral care. R199's care plan dated 08/21/24 documents in part: Focus: R199 has an ADL self-care performance deficit related to (r/t) Atherosclerosis of Native Arteries of extremities . Need for assistance with personal are care. The facility's policy dated 11/2015 and titled A.D.L. (Activities of Daily Living) Care documents, in part: Policy: To meet grooming and hygiene needs of residents with dignity and privacy. To encourage residents to achieve independence while providing the assistance needed. The basics for ADL care should be implemented whenever a procedure or task occurs. Safety Razor: . If the resident is a women shave only the areas with facial hair and apply facial moisturizer instead of aftershave. The facility's job description titled Certified Nursing Assistant (CNA) documents, in part: A Certified Nursing Assistant (CNA) provides quality nursing care to residents while implementing specific procedure and programs related to resident care under supervision of assigned Charge Nurse (LPN (Licensed Practical Nurse), RN (Registered Nurse)). Certified Nursing Assistant (CNA) Essential Duties and Responsibilities: Attends to residents' activities of daily living which may include assistance with feeding, grooming, transferring, ambulation, and range of motion, communicating or other needs in keeping with the individuals' care requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 15 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assure that emergency medical equipment stored to be used in emergency basic life support was checked daily. This deficient practice has the potential to affect all Fifty seven residents that reside on the 3rd floor of the facility. Findings include: On [DATE] at 10:50am crash cart checklist observed with daily checks only for [DATE], [DATE], and [DATE]. Observed missing crash cart daily checks for [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 11:01am V4 Licensed Practical Nurse (LPN) stated, The crash cart should be checked every day. The crash cart should be checked every day to make sure we (staff) have supplies in case of an emergency. When the crash cart is not checked and it's an emergency the resident could be in danger. On [DATE] at 10:46am V2 Director of Nursing (DON) stated, The crash carts have basic things for emergencies. The crash carts have oxygen tubing, IV (intravenous) starter kits, IV fluids, the suction machine and everything needed for suction, and a glucometer. It's important to check the things on the outside of the crash cart on a daily basis to make sure the CPR (Cardiopulmonary Resuscitation) board is there, and a nebulizer machine is there and to make sure the oxygen tank is at least half full. We (staff) do check the inside of the crash cart on a weekly and monthly basis or when it has been opened, to make sure that everything on the inside is up to date. The purpose of checking the crash cart daily is to make sure everything is available for an emergency and to be prepared and not have to search all over for things and to save time because every minute counts in an emergency. Facility's policy titled Crash Cart Procedures dated 10/2021 documents in part, Purpose: To organize and maintain the emergency cart (Crash Cart) to ensure adequate needed equipment for CPR (Cardiopulmonary Resuscitation) and emergency procedures .Policy: 1. The charge nurse will ensure the equipment are stocked in the Crash Cart .5. Crash cart will be checked daily to ensure that the carts locked and has not been opened. Facility's undated job description titled Licensed Practical Nurse (LPN) documents in part, A Licensed Practical Nurse is responsible for supervising nursing personnel while ensuring our residents' needs are met in accordance with professional standards of practice through physician orders, center policies and procedures, and federal, state and local guidelines .Licensed Practical Nurse (LPN) Essential Duties and Responsibilities: Works using the guidelines established from the Nurse Practice Act and Policies and Procedures and nursing judgement .Maintains knowledge of equipment set-up, maintenance and use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 16 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe environment with unsecured shaving razors left in the unlocked shower room; failed to provide a safe environment with liquid body soap left unsecured in a drinking cup in a resident's room and in the unlocked shower room; failed to provide a safe environment with the laundry chute left unlocked accessible to residents; failed to implement care planned fall precaution interventions; failed to update a care plan with an observed fall intervention in place; and failed to follow the facility's fall prevention policy and procedure. These failures affected two residents (R14, R146) and have the potential to affect 57 residents on the 2nd floor, 57 residents on the 3rd floor and 52 residents on the 4th floor. Findings include: On 9/8/24 at 10:49 am, this surveyor observed R146's door closed, and a contact isolation sign posted outside R146's closed door. This surveyor donned appropriate personal protective equipment (PPE) and entered R146's room. This surveyor observed R146 laying sideways in bed 1 with R146's body perpendicular to length of the bed. Bed 1 is a regular bed (not a low bed). R146 observed confused, mumbling to self, and rubbing hands together. R146 then sits up to the side of the bed (bed-1), stands up with no shoes on, and begins walking around R146's room. This surveyor observed a folded-up fall mat in the room in between bed 1 and 2. This surveyor checked R146's bathroom and observed a clear plastic drinking cup with viscous, bright blue liquid in it on the back of the toilet. The blue liquid fills the cup about 1/3 full. This surveyor requested for assistance within R146's room, and V22 (Registered Nurse, RN) responded wearing appropriate PPE to enter R146's room (at 10:52 am). When asking V22 about R146's status, V22 stated that R146 is nonverbal, and R146 walks around. R146 observed walking randomly around room. This surveyor informed V22 that when this surveyor entered R146's room, R146 was observed laying sideways in bed 1. V22 stated that bed 1 is not R146's bed, and that R146's bed is bed 2 which is a low bed. V22 stated, Yes, (R146) is a fall risk. When asked about the folded-up fall mat in R146's room, V22 stated, I (V22) believe it's (R146's). There's no one else in the room. (R146) is on isolation. This surveyor showed V22 in R146's bathroom and asked what this blue liquid is, and V22 stated, I don't know, but it looks like liquid soap. V22 picked up the clear plastic drinking cup containing the blue liquid, and this surveyor smelled it to be fragrant like soap or detergent. V22 stated that there is shower liquid soap in the shower room that is blue, and it looks like this. When asked if shower liquid soap is different than the foam soap used for hand washing in the dispenser in R146's bathroom, V22 stated, Yes. When asked should this blue shower liquid soap be stored like this in an open drinking container with R146 walking randomly around room, V22 stated, No, it should not be. When asked if this is considered a hazard for R146, V22 stated, Yes, it is. This surveyor then walked to the shower room on the 4th floor with the door not locked, and asked V23 (Certified Nursing Assistant, CNA) to accompany this surveyor in the 4th floor shower room. This surveyor observed in one shower stall a dispenser attached on the wall with a push bar to dispense the liquid blue soap; however, the lid (cover) to the top of the dispenser is missing, so this surveyor can see the liquid blue soap with same scent as the one in R146's bathroom. When asked V23 (R146's assigned CNA) if V23 cleaned R146 already this morning, V23 stated that V23 only provided incontinence care and denies she seeing the clear plastic drinking cup containing blue liquid shower soap in R146's bathroom. On 9/8/24 at 11:04 am, V22 (RN) informed this surveyor that the floor mat in R146's room is not for R146, and R146 is ambulation with supervision. V22 stated that R146 is on the falling star program (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 17 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm and pointed to R146's name plate outside the door with yellow tape noted. When asked what this falling star program signifies, V22 stated, We (staff) monitor them. (R146's) ambulation with supervision. When asked how can R146 be supervised with the door open, V22 stated, We are doing rounds on (R146). I usually do rounds. I cannot leave door open because (R146) will come out. R146 confirmed that it was the blue liquid body soap that was in the clear plastic drinking cup in R146's bathroom. Residents Affected - Some R146's admission Record documents, in part, R146's diagnoses of history of falling, zoster with other complications, dementia, chronic kidney disease, spontaneous ecchymosis, major depressive disorder, hypertension, hypercholesterolemia, and insomnia. R146's Minimum Data Set (MDS), dated [DATE], documents, in part, that R146's Brief Interview for Mental Status (BIMS) score was not conducted. R146's Staff Assessment for Mental Status was conducted which indicates that R146 has short and long term memory problems, and R146's Cognitive Skills for Daily Decision Making is severely impaired. R146's Behavior for Wandering typically occurs every 1 to 3 days. R146's Functional Abilities and Goals for Self-Care documents, in part, that R146's Shower/bathe self: The ability to bathe self, including washing, rinsing, and dry self is coded as substantial/maximal assistance-helper (staff) does more than half the effort; and R146's Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility is coded as partial/moderate assistance-helper (staff) does less than half the effort. R146's Functional Abilities and Goals for Mobility documents, in part, that R146 is coded as supervision or touching assistance-helper (staff) provides verbal cues and/or touching/steadying . as resident completes activity for rolling left to right in bed, for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns and walk 150 feet. R146's Order Summary Report documents, in part, an order of Fall Precautions with an active order status of 1/12/21. R146's Care Plan documents, in part, a focus of R146 at risk for falls related to dementia, psychosis, history of falls, major depressive disorder, generalized anxiety, insomnia, spontaneous ecchymosis, medications regimen (dated initiated 1/12/21, revision date 12/28/23) with an intervention of ensure shoes or gripper socks at all times (dated initiated 1/13/21); low bed (dated 6/10/24); Falling Star Program (date initiated 7/19/23, revision date 3/13/24); and keep all walkways free of hazards and maintain adequate lighting (dated initiated 1/13/21). On 9/9/24 at 12:55 pm, V37 (Licensed Practical Nurse, LPN) and this surveyor toured inside the unlocked shower room on 4th floor. V37 escorted this surveyor in the 4th floor shower room which has 2 doors which were unlocked. V37 said that anyone can go in or out either of the 2 unlocked doors. V37 showed the 3 separate shower stalls with all 3 shower liquid soap dispensers full of the blue liquid shower soap with no lids covering the top of the shower liquid soap dispensers. V37 stated that the blue soap is the shower liquid soap and is filled by the housekeeping staff. On 9/9/24 at 1:13 pm, when asked what is the blue liquid in the shower rooms on the floors, V36 (Housekeeping Director) stated, It's shampoo for their head and body wash for the residents. When asked where it is stored for usage for residents, V36 stated, It's only in the shower room. V36 stated that the soap dispensers in the residents' room bathrooms are for hand washing; comes out from the dispenser as foam when the person pushes the bar on the dispenser; and is different from the shower liquid soap. V36 stated that the hand soap from the dispenser in the residents' room bathrooms comes in a prefilled container that the housekeepers refill in the dispensers. V36 stated that the shower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 18 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some liquid soap is delivered to the facility in a gallon container, and the housekeeper will pour it into the dispenser. V36 stated that there is a lid on top of the shower liquid soap dispenser that the housekeeper removes, then pours the shower liquid soap into the dispenser and replaced the lid on top of the dispenser. V36 stated that then the CNA will push the bar on the front of dispenser to get a hand full of the shower soap. This surveyor informed V36 of the 3 shower stalls on the 4th floor with the shower liquid soap dispensers with no lids on top. V36 said, There's usually a lid but sometimes they open it (shower liquid soap dispenser) to get inside of there and the lid is lost, or we can't find the lids. When asked who is 'they,' V36 stated, The CNAs. V36 stated the CNAs will take a plastic drinking cup and scoop into the uncovered shower liquid soap dispenser to remove the shower liquid soap instead of using the bar to dispense it properly. V36 said that the CNAs will take the drinking cup of the shower liquid soap into the residents' rooms. V36 stated, There should be a lid on it (shower liquid soap dispenser), and it should not be open like that. It's for their (residents) safety. V36 stated that the shower liquid soap is for the resident's hair and body wash, and if left accessible to residents, they could use it inappropriately. On 9/10/24 at 11:49 am, when asked how staff prevent residents from falling in the facility, V2 (Director of Nursing, DON) stated that to prevent falls, the restorative and IDT (interdisciplinary team) team are involved with the falling star program. V2 stated, The falling star program is for every patient (resident) who is at high risk for falls. There are yellow stickers on the room name plate and it's on their equipment. When asked should all fall prevention interventions be care planned for, V2 stated, Yes. When asked V2 the expectations of the facility's nursing staff to follow the care planned fall interventions, V2 stated Yes, Yes, I (V2) do. V2 stated that the care planned fall interventions are individualized for each resident and each fall incident. V2 stated, If resident is ambulatory, we (staff) monitor (resident) more. Monitor (resident) in the day room, especially on the 4th floor. Residents who keep pacing or moving around on fall precautions are in the day room with activities, so someone is watching them continuously. When asked about footwear of this ambulatory resident on the 4th floor, V2 stated that staff encourage residents to wear the appropriate footwear when ambulating. When asked if barefoot is a safe way to ambulate with a dementia resident, V2 stated, No. Not to go barefoot. We encourage (residents) not to go barefoot and to wear socks with the non-skid sole. This prevents them (residents) from slipping. Some residents don't want to wear shoes, so they wear these. When asked how a resident can have a floor mat in the room when not care planned for, V2 stated that if a nurse will see that there is a concern for a high fall risk on that day, and the resident is more confused, then the resident may need the floor mat as a new intervention. When asked if it is a hazard (folded up floor mattress) in the resident's room who is ambulatory with dementia, V2 stated If it's in the middle of the room. The individual with dementia will not know and will get up anyway from bed so it's not appropriate to be using a fall mat. When asked if it's not care planned for and not being used for this dementia ambulatory resident, where should the floor mat be stored, and V2 stated, It should be removed from the room. When asked about a dementia ambulatory resident in an isolation room, like R146 (contact isolation), V2 stated that staff will supervise the resident. When asked how can staff supervision be done with the resident's door closed, V2 stated, The only thing we can do is to redirect (R146) to prevent (R146) from coming out of the room. When asked again how staff can be supervising R146 for fall prevention behind R146's closed room door, V2 stated, We have to round more. V2 stated that the floor should be clear from clutter for R146's fall prevention. When asked about the residents' shower rooms, V2 stated that there is liquid soap in the dispensers in the shower room and that the facility provides the residents with the liquid soap provided. V2 stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 19 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nursing staff will obtain the shower liquid soap from the dispensers by pressing the bar on the dispenser to express the liquid soap. V2 stated, Nursing staff should use the shower liquid soap in the same area (shower room). When asked if V2 expects the nursing staff to obtain the shower liquid soap from the shower room with a plastic drinking cup and bring it into the resident's room for use, V2 stated, No. No. No, they should not. When asked if V2 expects the nursing staff to leave the plastic drinking cup containing the shower liquid soap in the resident's room or bathroom, V2 stated, No. They (nursing staff) can forget about it in the cup on the dementia unit and any resident can mistake it and taken (swallow) it. This surveyor informed V2 that on 9/8/24 and 9/9/24, the shower room liquid soap dispensers were observed with no lids (covering) on top of the dispensers, and that V36 (Housekeeping Director) informed this surveyor that CNAs are scooping out the shower liquid soap out of the dispensers in the shower room to bring into resident rooms. V2 stated, They (nursing staff) should not be. They should not be. V2 stated, The shower room is accessible to all residents on the floor, and the shower liquid soap being easily accessible to residents is a safety hazard. V2 stated that staff securing the shower liquid soap is for the safety of the residents. On 9/9/24 (after V36's interview at 1:13 pm), this surveyor requested from V36 the Safety Data Sheets for the blue shower liquid soap observed in the shower room dispensers and was provided the following documents: Safety Data Sheet Finished Product: Infuse Lavender Mint Body Wash (2/4/22); Safety Data Sheet Finished Product: Infuse Lavender Mint Conditioning Shampoo (2/4/22); Safety Data Sheet Finished Product: Infuse Lavender Mint Conditioner (2/4/22); and Safety Data Sheet Finished Product: Infuse Lavender Mint Shampoo. All of the above Safety Data Sheets document, in part, This mixture is not considered a hazard when used in a manner which is consistent with the labeled directions of Topical Use Only. Facility document titled Daily Census and dated 9/8/24 documents, in part, that 52 residents are residing on the 4th floor of the facility, and R146's dual room is occupied only by R146. Facility policy dated May 2015 and titled Fall Management documents, in part, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to a resident's specific risks an (and) causes to try to prevent the resident from falling and try to minimize complications from falling. Risk: . Fall Prevention Activities Pre and Post Falls: 1. All residents shall be screened for the potential for falls, using the blank upon admission, be admission, quarterly, with significant change or as fall occurs. Staff will initiate falling prevention protocol . 4. For residents who have been identified at risk for falls upon admission, a care plan shall be developed which includes' the resident and/or his/her family input for interventions that have or have not worked in the past. Additional interventions will be developed to promote a safe environment. The residents' individualized needs for staff assistance will be assessed. Then the resident will be placed on a fall prevention program. 5. The effectiveness of each resident's care plan as it relates to fall prevention shall be monitored and documented as needed, as fall occurs and/or on a quarterly basis. Facility policy dated June 2012 and titled Falling Star Program Policy documents, in part, Policy: To ensure all residents determined to be at risk for falls or who have fallen are properly monitored by initiating the falling star protocol. Facility policy dated May 2015 and titled Fall Risk Screening Policy documents, in part, Policy Statement: The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls. Policy Interpretation and Implementation: . 7. The staff will seek to identify environmental factors that may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 20 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contribute to falling, such as lighting and room layout . 9. The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Facility policy dated May 2015 and titled Accidents and Incidents: Supervision, Investigating and Reporting documents, in part, Statement: The facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard in risk, evaluating and the analyzing hazard in risk, implementing interventions to reduce hazard and risk, monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current standards of practice such as drug side effects or reaction. Avoidable Accident means that an accident occur because the facility failed to identify an environmental hazard or individual risk or the need for supervision and/or evaluate/analyze the hazard and risk and/or implement interventions consistent with the residents needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident and/or monitor the effectiveness of the interventions and modify the interventions as necessary in accordance with the current standards of practice . Hazards refer two elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness. Free of accident hazard as is possible refers to being free of the accident hazard over which the facility has control. Resident environment includes the physical surroundings to which the resident has access . Adequate Supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment. Identification of Risk and Hazards: The areas assessed include the residents' room and surrounding environment, physical plant, equipment devices that are defective or not used properly, residents' individual risks factors and need for supervision . Implementation of Interventions: This includes adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment, educating resident and staff . Interventions includes supervision and other actions that could address and reduce the potential for negative outcomes. This includes providing a safe environment . Supervision: Monitoring there is sufficient staff based on residents' needs which can vary. Such needs could include: behaviors such as unsafe wandering . Limited cognitive abilities, limited safety awareness, history of falls . Making staff aware of plan and interventions to reduce to a residents risk for an accident. Facility job description (undated) titled Certified Nursing Assistant (CNA) documents, in part, A Certified Nursing Assistant (CNA) provides quality nursing care to residents while implementing specific procedures and programs related to resident care under supervision of assigned Charge Nurse (LPN or RN). Certified Nursing Assistant (CNA) Essential Duties and Responsibilities: Provides individualized attention to residents which encourages each resident's ability to maintain or attain the highest practical physical, mental and psychosocial well-being . Contributes to the resident care planning process by providing the charge nurse or other care planning staff with specific information and observations of the residents' needs and preferences. Attends to residents' activities of daily living which may include assistance with feeding, grooming, bathing, oral hygiene, feeding, incontinent care, toileting, colostomy care, prosthetic appliances, transferring, ambulation, and range of motion, communicating or other needs in keeping with the individuals' care requirements . All other duties as assigned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 21 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Facility job description (undated) titled Housekeeper documents, in part, Housekeeping personnel are responsible for keeping our facility clean and safe for residents, staff and visitors. Housekeeper Essential Duties and Responsibilities: Follows all housekeeping departmental policies and procedures . Uses proper sanitation and safety procedures . Promotes a safe resident environment by properly securing housekeeping carts in a locked area when not in use. Assures all chemicals are stored in a locked area and inaccessible to residents at all times. Findings include: R14 has a diagnosis which includes but not limited to: history of falling and pain in left wrist. R14 has a Brief Interview for Mental Status (BIMS) dated 08/14/24 that shows a score of 11 which indicates that R14 has moderate cognitive impairments. R403 has a diagnosis which includes but not limited to: Bilateral primary osteoarthritis of knee, hypertension, and asthma. R403 has a Brief Interview for Mental Status (BIMS) dated 09/10/24 does not indicate a score for R403. R403 face sheet indicates that R403 was admitted to the facility on [DATE] and R403's Minimum Data Set (MDS) is not yet complete. During this survey, Surveyor interviewed R403 and R403 was able to answer questions appropriately. On 09/08/24 at 10:27 am, R14 stated that R14 has had multiple falls in the past month at the facility. R14 explained that R14's last fall, was one week ago when R14 rolled from R14's bed onto the floor in R14's room. R14 then explained that R14 was given a floor mat to be placed next to R14's bed. Surveyor observed a floor mat on the floor in R14's room to the left of R403's (R14's roommate) bed. Surveyor questioned R403 regarding the floor mat to the left of R403's bed in R14 and R403's room and R403 stated, That is not mine. That is hers (referring to R14). R14 then stated, They gave that to me (R14) when I (R14) fell out the bed last week. I (R14) don't know how it (referring to the floor mat next to R403's bed) got over there. On 09/08/24 at 11:57 am, Surveyor brought this observation to R14 and R403's nurse on 09/08/24, R3 (Infection Preventionist, IP, Registered Nurse, RN) and V3 stated, R14 is a fall risk. That floor mat is for R14. It (referring to the floor mat to the left of R403's bed) should be next to R14's bed. Surveyor observed V3 move the floor mat from next to R403's bed and place the floor mat next to R14's bed. When V3 was asked regarding the importance of R14's floor mat being next to R14's bed while R14 is in bed and V3 stated, To protect R14 from falling on the floor. On 09/10/24 at 11:39 am, Surveyor questioned V2 (Director of Nursing, DON) regarding the facility's policy for fall interventions and V2 stated that when a resident sustains a fall, a fall intervention is immediately put into place to prevent the resident from falling again. V2 then explained that fall interventions that are put into place should be documented on the residents care plan so that all staff are aware of the plan of care for the resident. V2 further explained that residents should not have fall interventions in place that are not care planned for the resident. When V2 was asked regarding the importance of documenting fall interventions for a resident on the residents care plan, V2 stated, So all staff know the interventions in place to prevent a resident from sustaining a fall. The facility's undated policy titled Care Plans - Comprehensive documents, in part: Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 22 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. The facility's document dated 09/01/24- 09/09/24 and titled Incident by Incident shows that R14 sustained a fall on 09/05/24 at 2:15 am and 09/05/24 at 4:00 am. The facility's document dated 05/2015 and titled Fall Management documents, in part: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the residence specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. 6. As a fall occurs the nurse on duty will initiate a new intervention to prevent further falls the plan of care will be updated at this time period the revisions to the fall of care will be monitored for effectiveness and adjustments made as needed. The fall committee will review the revised plan of care and the residents response at fall committee. The facility's document dated 06/2012 and titled Falling Star Programs Policy documents, in part: Policy: To ensure that all residents determined to be at risk for falls or have fallen are properly monitored by initiating the falling star protocol. Procedure: 4. Individualized care plan will be initiated, and immediate intervention will be put into place. 8. Recommendations and updating of individualized interventions will be implemented in documented on the residence care plan. The facility's document dated 06/20152 and titled Fall Prevention Activities for All Residents documents, in part: 1. All residents shall be screened for the potential for fall, using the fall risk screening tool upon admission, readmission, quarterly, with significant change or as fall occurs. Staff will initiate falling star protocol. 4. For residents who have been identified at risk for falls upon admission, a care plan shall include interventions to promote a safe environment and resident placed in a fall star program. The facility's document dated 05/2015 and titled Fall Risk Screening Policy documents, in part: Policy Statement: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls. Policy Interpretation and Implementation: 10. The care plan for prevention will be developed and updated when a fall occurs or as needed including the identified risks and development interventions. R14's Fall Risk Evaluation dated 09/05/24 at 5:00 am, shows that R14 sustained a fall. R14's Fall Risk Evaluation dated 09/05/24 at 5:55 am, shows that R14 sustained a fall. R14's progress noted dated 09/05/24 5:04 am, authored by V48 (Licensed Practical Nurse, LPN) documents that R14 sustained a fall. R14's progress noted dated 09/05/24 5:57 am, authored by V48 (LPN) documents that R14 sustained a fall. Findings include: On 09/08/24 at 10:29am observed linen chute room with paper towel blocking the lock hole and the door easily pushes open and is accessible to residents. Linen chute without lock, easily opens. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 23 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 09/08/24 at 10:32am V26 Certified Nursing Assistant (CNA) stated, I'm not sure who put the tissue in the door hole. The laundry chute room should be locked because it's a safety risk for the residents. The residents could fall down the chute and many things could happen, it's a long way down. On 09/10/24 at 10:46am V2 Director of Nursing (DON) stated, The linen chute room should be always closed and locked. If it is not locked it is accessible to the residents and other people that should not go in there. If a resident goes in the linen chute room, they could put things that don't belong in there and it is a pretty big hole, and I don't want to think of what could happen if the residents goes down the hole. FACILITY ACCDNTS Record review of daily census roster dated 9/8/24, indicates that 57 residents reside on the second floor of the facility. On 09/08/24 at 10:14 AM, surveyor observed an open bag of disposable razors on top of the sharps container in the 2nd floor shower room. Additionally, surveyor observed 2 used disposable razors on top of the sharps container's opening. On 09/08/24 at 10:16 AM, V3 (Infection Preventionist) observed the razors and immidiately disposed of the razors into the sharps container and grabbed the open bag of razors. V3 stated that the razors should be kept secured because any resident on the second floor could have access to them and hurt themselves. V3 affirmed that there are ambulatory residents that could have access to the shower room without staff present. On 9/10/24 at 11:07, V1 (Administrator) stated that razors used for shaving should always be disposed of properly and not left unattended. Record review of facility policy dated 11/2015 titled A.D.L CARE, documents in part, .Upon completion of procedure, remove gloves if worn, wash your hands. Clean the equipment and return it to the correct storage space. Discard used disposable equipment in designated containers . SAFETY RAZOR . Discard the safety razor in the sharps container . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 24 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Some R303 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Hypertension, Pulmonary Embolism Without Acute Cor Pulmonale and Type 2 Diabetes Mellitus. R303 has a Brief Interview of Mental Status score of 11. R303's care plan focus for altered respiratory status with a revision date of 7/29/2024 documents, in part, Oxygen settings: O2 (oxygen) at 3L (Liters) per nasal canula. On 9/08/2024 at 10:02am surveyor observed R303's oxygen tubing with a piece of tape dated 8/23 and the humidifier bottle dated 8/06/2024. R36 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Severe Protein-Calorie Malnutrition, Hypertension, Rheumatoid Arthritis and Anorexia. R36 has a Brief Interview of Mental Status score of 09. R36's care plan focus for risk for potential complications: SOB (Shortness of Breath), Respiratory Infections, documents, in part, Oxygen Settings: Oxygen per Nasal Cannula at 2 liters/minute continuous every shift Monitor and Record that O2 Sats (Saturation) remain above 95%. On 9/08/2024 at 10:23am surveyor observed R36's undated oxygen tubing. R36 stated that she thinks the nurse changed her tubing yesterday on 9/07/2024. R163 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Vascular Dementia, Chronic Obstructive Pulmonary Disease, Cerebral Infarction and Anemia. R163 has a Brief Interview of Mental Status score of 03. On 9/08/2024 at 10:30am surveyor observed R163's undated oxygen tubing. On 9/10/2024 at 12:32pm V2 (Director of Nursing-DON) stated that oxygen tubing is changed weekly and as needed and the nurses are required to label the oxygen tubing and humidifier bottle with the date the tubing and bottle have been changed. Oxygen Administration policy with a revised date of 3/2020 documents, in part, oxygen tubing and humidication bottles are to be changed weekly and as needed, tubing and humidification bottles are to be dated at the time they are changed. Based on observations, interviews, and record reviews, the facility failed to ensure the nebulizer mask was contained, failed to ensure the oxygen tubings and humidifier bottles were labeled with dates when changed, and failed to ensure oxygen tubings and humidifier bottles were changed per facility policy. These failures affected 4 (R36, R142, R163, and R303) residents reviewed for respiratory care in the total sample of 76 residents. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 25 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 On 09/08/24 at 11:14 AM, R142's nebulizer mask was on top of R142's night stand, not contained. Level of Harm - Minimal harm or potential for actual harm On 09/08/24 at 11:16 AM, this observation was pointed out to V15 (Registered Nurse). V15 stated her (R142)'s nebulizer mask is not in plastic container. Residents Affected - Some On 09/10/2024 at 2:53pm, V2 (Director of Nursing) stated the nebulizer mask should be in a plastic container when not in use to prevent cross contamination. It is an infection control issue if not contained. R142's (Active Orders as of: 09/09/2024) Order summary Report documented, in part Diagnoses: (include but not limited to) chest pain, COPD (chronic Obstructive Pulmonary disease), and acute respiratory failure with hypoxia. Order Summary. Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 6 hours as needed for shortness of breath. R142's (08/01/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 12. Indicating R142's mental status as moderately impaired. R142's (09/2024) MAR (Medication Administration Record documented that R142 was administered Ipratropium-Albuterol solution on 09/07/2024 and 09/09/2024. This as needed medication was not administered on 09/08/2024. R142's (09/07/2024) Medication Administration Audit Report documented that R142 was administered Ipratropium-Albuterol solution at 12:02 (pm). R142's (07/30/2024) care plan documented, in part has an acute hypoxic respiratory failure. Will display optimal breathing patterns daily. Give medication as ordered. The (3/20) Nebulizer Administration documented, in part Purpose: The purpose of this procedure is to provide guidelines for safe administration of nebulized medication. General Guidelines: d. Nebulizer Masks and T-piece Mouth apparatus will be covered and stored when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 26 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview, and record review, the facility failed to ensure employees' personal food items were not stored in the Kitchen's walk-in cooler; failed to ensure the ceiling is not leaking and the drainage pipe is not clogged at the dishwashing area inside the kitchen in an effort to prevent food borne illnesses. These failures have the potential to affect all residents taking oral nutrition at the facility. Findings include: The (09/08/2024) census report documented that there were 204 residents at the facility. The (09/09/2024) Diet Type Report documented that there were 3 residents not taking oral nutrition at the facility. On 09/08/2024 at 9:21am, there were 4 small food baskets inside the walk-in cooler with V9's (Cook), V11's (Dishwasher), V12's (Dietary Aide), and V14's (Cook) names. V9 stated these (small food baskets) are for the Kitchen staff. They (facility) let us (Kitchen staff) keep our food in the walk-in cooler because we (Kitchen staff) don't have a place to keep our food. On 09/09/2024 at 9:43am, there was a puddle of water by the dishwashing area. V28 (Dietary Aide) stated we (kitchen staff) are running the dish machine and when the water from the dish machine gets to the drain the water goes back up. I (V28) think the drain is clogged. On 09/09/2024 at 9:46am, this observation was pointed out to V8 (Dietary Supervisor). V8 stated there should be no water on the floor because it is unsafe and unsanitary. On 09/09/2024 at 9:47am, walking towards the dish machine noted 2 buckets on the floor, directly were the water leak from the ceiling was coming from. V8 stated there is a leak on the ceiling and it is coming from upstairs (residents' floor). On 09/09/2024 at 9:55am inside the walk in cooler, this surveyor pointed out to V8 the kitchen staff's personal food baskets. V8 stated I (V8) think it should be okay if they are labeled. This surveyor inquired if V8 is aware where staff got the food items. V8 stated I (V8) don't know where staff got their food. On 09/10/2024 at 10:10am, the ceiling inside the kitchen by the dish machine was still leaking. The (09/10/2024) email correspondence with V8 (Dietary Manager) documented, in part What is the importance of not having leaks on the ceiling and not having a clogged drain in the kitchen or dishwashing room area? V8 responded 'The importance of not having leaks on the ceiling and not having a clogged drain in the kitchen or room area is free from contamination for all the equipment that we used and safe place to work. The (undated) SANITATION & FOOD SAFETY: STORAGE OF REFRIGERATED FOODS: PERSONAL FOOD ITEMS documented, in part Policy: Refrigerated food is stored in a manner that ensures food safety PROCEDURE: The facility does not allow employees to store personal food items in the dietary department refrigerators or freezers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 27 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs for five residents; and failed to ensure that personal refrigerators had a refrigerator thermometer for three residents. These failures affected five residents (R17, R36, R101, R110, and R117) out of 76 residents in the total sample. Residents Affected - Some Findings include: R101 has a diagnosis which includes but not limited to unspecified dementia, gastrostomy status, unsteadiness on feet, supraventricular tachycardia, generalized anxiety, post covid condition, and gastritis. R101 Brief Interview for Mental Status (BIMS) dated 07/19/24 documents that R101 does not have a BIMS score and indicates that R101 has memory problems. On 9/08/2024 at 10:25am surveyor observed R36's personal refrigerator without a thermometer and a temperature log. On 9/08/2024 at 10:33am surveyor observed R17's personal refrigerator without a thermometer and a temperature log. On 9/08/2024 at 10:35am V5 (Certified Nursing Assistant-CNA) stated resident's personal refrigerators are supposed to have a temperature log and a thermometer. V5 said, No, I don't see a thermometer and I will have to tell maintenance. On 09/08/24 at 10:37 am, Surveyor observed R101's personal room refrigerator without a refrigerator temperature log sheet for September 2024 and without a refrigerator temperature thermometer in R101's personal refrigerator. On 09/08/24 at 11:51 am, V3 (Infection Preventionist, IP, Registered Nurse, RN) was observed as the second-floor nurse for R101. V3 stated that the nurses and CNA's on the unit are responsible for checking the residents personal refrigerators on the unit every day. V3 explained that the nurses and CNA's should be monitoring and recording the residents personal refrigerator temperatures on a temperature log sheet that is kept visible on the outside of the residents refrigerator daily. When V3 was asked regarding the residents personal refrigerators having a thermometer and monitoring the residents personal refrigerators on a temperature log sheet V3 stated, So that residents don't consume spoiled food and get sick. On 09/10/24 at 11:47 am, V2 (Director of Nursing, DON) stated that it is the housekeeping department is responsible for checking the residents personal refrigerators during the day and the night shift nurses are responsible for checking the residents personal refrigerators during the nighttime. V2 explained that the nurses are expected to check the residents personal refrigerators temperatures daily and record the temperature of the personal refrigerator on the residents personal refrigerator log sheet. When V2 was asked regarding the importance of the residents personal refrigerators being checked daily and logged onto the residents personal refrigerator log sheet V2 stated, To make sure the temperature is appropriate, and food doesn't spoil. On 9/10/2024 at 12:32pm V2 (Director of Nursing-DON) stated the night shift nurses and nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 28 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff are responsible for checking the temperature, completing the temperature log and replacing the thermometer in the residents personal refrigerators. V2 stated that harm in not checking the temperature of the resident's personal refrigerators or not having a thermometer poses a high risk for infections. On 09/10/24 at 11:52 am, V36 (Housekeeping Director) stated that it is the responsibility of the housekeepers and the nursing staff at the facility to check the residents personal refrigerators. V36 explained if the nursing department checks the residents personal refrigerators first then the nursing staff should record the residents personal refrigerator temperature onto the resident personal refrigerator log sheet. V3 stated that all personal refrigerators should have a thermometer and refrigerator log sheet to record the refrigerator temperature. When V3 was asked regarding the importance of the residents personal refrigerators having a temperature thermometer and log sheet and V3 stated, If the refrigerator is not checked then the food can get spoiled and be no good. The facility's undated policy titled Resident Refrigerator documents, in part: Policy Statement: This facility will ensure safe refrigerator maintenance, temperature, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 2. Monthly tracking sheets for all refrigerators will be posted to record temperatures. 3. Designated employees will check and record refrigerators temperatures. The facility's job description titled Housekeeper documents, in part: Housekeeping personnel are responsible for keeping our facility clean and safe for residents, staff and visitors. Housekeeper Essential Duties and Responsibilities: Follows all housekeeping departmental policies and procedures. Findings include: On 09/08/24 at 10:35am R117's refrigerator temperature log observed with missing dates and multiple personal food items inside. On 09/08/24 at 10:41am R110's refrigerator observed with no refrigerator log on or near R110's refrigerator. Multiple prepackaged meals noted in R110's refrigerator. On 09/08/24 at 10:43am V21Certified Nursing Assistant (CNA) stated, The nurse or the CNA can check the refrigerator. The refrigerator should be checked every day so we can know the temperature of the food in the refrigerator to make sure food doesn't spoil. All the personal refrigerators should have a temperature log. R117's refrigerator is missing some dated checks on R117's refrigerator. This resident (R110) doesn't have a temperature log on the refrigerator. On 09/08/24 at 11:07am V6 Nursing Supervisor (NS) stated, The refrigerators should be checked daily and is the responsibility of nursing and housekeeping. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 29 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure cigarette butts were contained and not blown towards the generator's fuel tank in an effort to prevent fire. This failure has the potential to affect all residents residing at the facility. Findings include: On 09/09/2024 at 9:36am with V9 (Cook) at the facility's docking area, noted a big red tank with signs posted FLAMMABLE. KEEP FIRE AWAY and '270GHL'. Cigarette butts were noted inside the trash can adjacent to the fuel tank, under the fuel tank, on the drain cover, and on the surrounding of the docking area. These observations were pointed out to V9. V9 stated that's Maintenance's job. This surveyor called for the maintenance. On 09/08/2024 at 9:47am with V10 (Dishwasher) translating for V13 (Maintenance). This surveyor pointed out to V13 the cigarette butts under the fuel tank, inside the plastic trash can, drain cover, and on the surrounding of the docking area. V13 stated staff are smoking close to the docking area and the wind blows the cigarette butts towards the fuel tank. I (V13) don't know their names. On 09/09/2024 at 10:13am, V25 (Activity Director) stated staff are not allowed to smoke on the patio. Only residents can smoke on the patio. On 09/09/2024 at 10:14am, V18 (Activities Aide) stated we (facility) have 5 receptacle bins for the cigarette butts. The purpose of the cigarette butt receptacle bins is to prevent fire. On 09/09/2024 10:19am at the facility basement with V30 (Maintenance Director) and V32 (Regional Maintenance Director), V30 stated the purpose of the cigarette butts receptacle is to keep the cigarette butts in place. Surveyor inquired if V30 provided cigarette butt receptacles for the staff. V30 stated all the receptacles are upstairs. On 09/09/2024 at 10:21am at the docking area, V30, pointing to the big red tank on the docking area, stated that is our fuel tank. On 09/09/2024 at 10:22am, while walking towards the dumpster this surveyor pointed out to V30 multiple cigarette butts along the way. V30 stated I (V30) don't know where's the staff smoking area. Staff should not be throwing the cigarette butts here. the Fuel in the fuel tank and the flame from the cigarette butt can cause a fire. On 09/09/2024 at 10:25am while doing an observation with V30 and V32 of the facility's dumpsters, V35 (Dietary Aide) walked towards the dumpster and lit a cigarette. V35 started to smoke. V32 informed V35 'you cannot smoke here. Of note, the dumpster site is adjacent to the docking area where the fuel tank is located. On 09/10/2024 at 3:32pm, V30 stated the fuel tank is for our generator and the tank has 270 gallons of fuel. The (09/11/2024) email correspondence with V27 (Assistant Administrator) documented, in part Do you have a policy specific to the fuel tank in reference to smoking? No, we do not. Are staff expected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 30 of 31 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to throw cigarette butts in a plastic trash can near or close to the fuel tank? The staff is expected to dispose of cigarette buds in a metal ash tray provided. The (09/09/2024 - 09/10/2024) email correspondence with V30 (Maintenance Director) documented, in part All staff will put all cig butts in ash trash in front of the building that's in the smoke area. The reason the facility provides ash tray it (is) to stop the spread of hot ashes and cigarettes butt around the facility. To prevent a fire. The (09/09/2024) Smoking Area documented, in part Summary of presentation: Employee smoking area is located in front of the building to the south. No employee shall smoke in any other area. The (06/01/2024) Employee Standards of conduct documented, in part In accordance with state law, all Facility's workplaces are non-smoking. Smoking is prohibited in all places of employment, including inside the facility premises and vehicles. Leaving cigarette or cigar butts or tobacco on the ground, in bushes, etc is littering and is prohibited. Smokers are responsible for disposing their cigarette and cigar butts and tobacco in an appropriate manner. The (11/18) State Long-Term Care Ombudsman Program Residents' Rights for people in Long-Term Care Facilities documented, in part Your rights to safety. Your facility must be safe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 31 of 31